An Assessment of the Psychosocial Evaluation for Early Liver Transplantation in Patients with Acute Alcoholic Hepatitis in the context of Alcohol Use Disorder, A Case Control Study

Abstract

Background Severe acute alcoholic hepatitis (AAH) has an excessive mortality rate. As a result, many centers, including our own, have allowed transplant listing patients for transplantation prior to achievement of 6-months sobriety. Concurrently, scoring systems have been proposed to identify patients with alcohol use disorder (AUD) predisposed to relapse after liver transplantation. These scoring systems target patients with a minimal period of sobriety. Methods We conducted a retrospective case control study of 11 patients who underwent early liver transplantation for AAH matched with 11 controls who were declined secondary to low insight into AUD. Blinded raters confirmed the severity of the DSM-5 diagnosis and scored the patients on a variety of structured psychometric scales used to predict alcohol relapse. These included the High Risk for Alcohol Relapse scale (HRAR), Stanford Integrated Psychosocial Assessment Tool (SIPAT), Alcohol Relapse Risk Assessment (ARRA), Hopkins Psychosocial Scale (HPSS), Michigan Alcoholism Prognosis Score (MAPS), Alcohol Use Disorders Identification Test -Consumption (AUDIT-C) and Sustained Alcohol Use Post-Liver Transplant (SALT) scales. All patients who underwent transplantation were followed for harmful and non-harmful drinking until the end of the study period. Results Mean psychometric scores of the transplanted cases were significantly different than the controls. Cases chosen for transplant had significantly favorable MAPS, HRAR, SIPAT, ARRA, and HPSS scores with cut-offs matching their prior research. The SALT and AUDIT-C scores were not predictive of our selection of patients for transplant. Despite expedited assessment and no significant period of sobriety, our case cohort had a 30% relapse to harmful drinking after an average of 6.6 years (5 to 8.5 years) of follow-up. Discussion Despite the expedited assessment and short to no period of sobriety, the patient cohort demonstrated a 30% relapse to harmful drinking, consistent with the reported 20-30% after liver transplantation for all forms of alcoholic liver disease. The average MAPS, HRAR, SIPAT, ARRA, and HPSS scores all corroborated our current stratification procedures, with lower risk mean scores found in the transplanted group. Conclusion The traditional psychosocial selection criteria for patients with alcoholic hepatitis at our institution is consistent with four of the five investigated scoring systems.